Healthcare Provider Details

I. General information

NPI: 1104770619
Provider Name (Legal Business Name): MALLORY ELLEN HOLDER CRNP
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MEDICAL CENTER DR
MONROEVILLE AL
36460-3036
US

IV. Provider business mailing address

16 MEDICAL CENTER DR
MONROEVILLE AL
36460-3036
US

V. Phone/Fax

Practice location:
  • Phone: 251-575-1999
  • Fax:
Mailing address:
  • Phone: 251-575-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-109040
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: